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M jjWaste Tire Su, �y & Inspection Report inspection Report Number <br /> State B California Il - 1140553 <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Z L <br /> Site Suffix: 3 2 4 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SClt�i ou Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Busin s Rep ` Titl /� O AM O AM <br /> 1J✓'c Sc,7•% p K� d 0 d * PM U :S— O 0 PM <br /> -i(OFperatonalI onel only)Status Fill ireTYPat aPPIY) (Filsall thpe <br /> at aPPIY) (File ine s Roleo)algthaty PPIY)! <br /> Tire Count (Whole/PTE) <br /> t♦ Active Q Passenger ! Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ®Truck <br /> i <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> / A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § g Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 10 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § _I <br /> Comments <br /> r /LO <br /> i <br /> Inspection Form Included- QI <br /> Comments Included: P -- — p 9 <br /> Bu ' e s Si ure Phone Number Sector's SI nature Phone Number <br /> -- o _. - r <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ect: Incorrect: X 1. 3 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Cop <br />